Bharati Jacob, founder-partner of Seedfund, a venture investment firm based in Bangalore, had her daughter vaccinated with the Human Papillomavirus (HPV) vaccine when she entered her teens. “My brother-in-law is a paediatrician and he recommended that I vaccinate my daughter. I am pleased I could do something to protect my daughter against cervical cancer," Jacob says.

Duru Shah, scientific director of Gynaecworld, Mumbai, recommends the vaccine to all her patients—teenagers and women in their early 40s alike. One of her patients who is in her 40s recently took the second of three doses of the HPV vaccine that are required to confer protection against the HPV infection. “My father died from gastric cancer, and my mother was recently diagnosed with uterine cancer," she says. “After seeing them suffer, I wanted to do what I could to protect myself from any kind of cancer."

On 2 June, actor Michael Douglas announced in an interview in The Guardian that his throat cancer had been caused by the HPV infection, a sexually transmitted disease.

Just how common is HPV? The World Health Organization (WHO) estimates that in 2010 HPV was responsible for up to 20% of head, neck and mouth cancers, 40-50% of penile cancers and 90% of anal cancers in men. In women, HPV was responsible for 82.5% of cervical cancers. This data is particularly relevant to India, since cancer of the cervix is the most frequent cancer among Indian women. According to WHO data, 134,000 Indian women are diagnosed with cervical cancer each year and roughly 70,000, or more than half of those diagnosed, die from it.

Anatomically, the cervix is the “neck" of the uterus and connects the uterus with the vagina.

Developed countries like the US have managed to limit the damage caused by cervical cancer—less than a third of those diagnosed with the disease die from it in the US, says Surendra Shastri, head, department of preventive oncology, WHO collaborative centre for cancer prevention, screening and early detection at the Tata Memorial Hospital, Mumbai. “This is because of the widespread use of the Pap test, a cervical cancer screening tool," says Dr Shastri. The Pap test allows for the early detection of cervical cancer and that leads to successful treatment and fewer deaths. The test can be done during a routine pelvic exam where cells are collected from the cervix and examined under a microscope.

Dr Shastri says the situation in India is very different from the US. “Most women in India, educated or otherwise will tell you that they haven’t had a Pap test, ever," he says. This is probably because of a lack of awareness compounded by gynaecologists not doing their bit to encourage women to take the test.

The success of the Pap test as a screening tool depends on how frequently it’s done and how many women have access to it. In the US, the recommendations are three Pap tests the first year that a woman is sexually active, and if those are normal, then a test every three-five years subsequently. “In India that kind of screening is just not feasible," Dr Shastri says. “My advice to women in India is that once they get to the age of 30 they should be Pap tested two-three times in their lifetime." Neerja Bhatla, professor, department of obstetrics and gynaecology, All India Institute of Medical Sciences, New Delhi, recommends a more stringent approach. She says women should get a Pap test done every three years after becoming sexually active.

Since the infrastructure in India makes systematic screening for a large section of the population impossible, there is another way out—the HPV vaccine. The vaccine provides immunity against two specific strains of the virus, HPV 16 and HPV 18, and protects both men and women from the HPV infection and the risk of cancer. “Together these two strains are responsible for over 80% of the cervical cancers in India," says Dr Bhatla.

There are two kinds of HPV vaccines available in India, Cervarix and Gardasil. Cervarix inspires immunity against HPV 16 and 18, while Gardasil inspires immunity against HPV 16, 18, 11 and 6. Both vaccines have to be taken over three doses, Gardasil has the added benefit of preventing HPV-related genital warts as well. HPV 11 and HPV 6 are responsible for 90% of the cases of genital warts; genital warts aren’t cancerous but can be unsightly.

The Universal Immunization Programme of India, administered by the Union health and family welfare ministry, provides free vaccinations for six preventable diseases—tuberculosis, diptheria, pertussis, tetanus, poliomyelitis and measles. Cervical cancer, preventable by the HPV vaccine, isn’t on the list.

So far, the HPV vaccination is not a compulsary part of the public health system in India.

Also, there are some Internet reports that suggest adverse medical reactions to the HPV vaccine in a handful of children and while there is no evidence to suggest the vaccine causes an untoward reaction or is in any way unsafe, some mothers feel conflicted about giving it to their daughters. Priya Sunder, director and co-founder of Peak Alpha Investment Services, Bangalore, says: “I am contemplating it for my 15-year-old daughter as my gynaecologist recommended it but I would like to get more information on the vaccine before I take that step. There have been some reports of adverse reactions in the media that are worrying."

Dr Shah and Dr Shastri both emphasize that the HPV vaccine is perfectly safe. The vaccine doesn’t come cheap, however. At 6,000 for three doses of Cervarix and 8,400 for Gardasil, cost will be a concern for many Indian parents.

Since HPV also causes cancers in men, the government of Western Australia announced in October that it would be vaccinating both girls and boys under the national HPV vaccination programme from 2013. Girls have been undergoing vaccination under this programme since 2007. After the vaccination was introduced, the number of women in the vaccination age group who have precancerous lesions in the cervix has gone down in Australia, suggesting that the vaccine works. The HPV vaccine is currently licensed for use in India only for young girls and women, and paediatricians aren’t allowed to administer it to boys. However, Gandhali Deorukhkar, obstetrics and gynaecology consultant, Gynaecworld, says she wants to vaccinate her son and hopes that the vaccine will be licensed for use in boys before her son is sexually active.

Sujata Kelkar Shetty, PhD, writes on public health issues and is a research scientist trained at the National Institutes of Health in Bethesda, US.

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